TITLE: GUIDELINE FOR ARKANSAS DEPARTMENT OF HEALTH HEPATITIS B

INSTRUCTIONS:

USE BLACK INK - PRINT ONLY

USE ALL CAPITAL LETTERS

ALL FIELDS ARE REQUIRED BUT IF NOT APPLICABLE THEN LEAVE BLANK.  DO NOT WRITE N/A.

1. Clinic code is:  6081
2. Mothers:  Last name, first name and middle initial
3. Mothers maiden name
4. Mothers medical record number
5. Mailing address
6. Mothers date of birth mm/dd/yyyy
7. Mothers Medicaid number if applicable
8. City, State and Zip code of mothers mailing address
9. Mothers home phone number including area code 123-456-7890
10. Mothers message phone number including area code  123-456-7890
11. Infants date of birth mm/dd/yyyy
12. Infants time of birth - 24 hours clock
13. Infants birth weight in pounds and ounces
14. Infants last name as it is to be on birth certificate
15. Infants first name (baby boy or baby girl is not acceptable)
16. Infants middle name if applicable
17. Home phone number including area code 123-456-7890
18. Infants Medicaid number if available
19. Fill in circle for infant gender
20. Fill in circle for infant race (race of mother)
21. Fill in circle for insurance coverage "Medicaid Pending" is the same as no insurance
22. Mailing address
23. Apartment number if applicable
24. City of mailing address
25. State of mailing address
26. Zip code of mailing address
27. Darken the circle "Yes" if mother is HBsAg positive (regardless of birth weight).  Fill in the date of lab draw mm/dd/yyyy.  Print "UAMS" for Name of Lab.  Proceed to 28a and 28b.
28. Darken the circle "Yes" if Infant is less than 2000 grams born to a mother whose HBsAg status cannot be determined within 12 hours of birth.  Fill in the date of lab draw mm/dd/yyyy.  Print in the Name of Lab area:  UAMS.  Darken the circle in front of the appropriate results positive or negative.  Proceed to 28a and 28b.

28a.  Complete the HBIG administration areas:

 Date given mm/dd/yyyy

 Time given –24 hour clock

 Route -IM

Site RL: right leg; RA:  right arm, LL: left leg; RL:  right leg.

Dose:  in milliliters, decimal provided. 

MFG: Manufacturer’s codes are printed under this area.

28b. Complete the Hepatitis B Vaccine administration areas:

 date given mm/dd/yyyy

 Time given –24 hour clock

 Route -IM

Site RL: right leg; RA:  right arm, LL: left leg; RL:  right leg.

Dose:  in milliliters, decimal provided. 

MFG: Manufacturer’s codes are printed under this area.

29. Darken the circle  “Yes” if mother had no prenatal care, draw HbsAg STAT!  .  Fill in the date of lab draws mm/dd/yyyy.  Name of Lab area: UAMS.  Darken the circle in front of the appropriate results positive or negative. Proceed to 29a and/or 29b.

    29a.  Complete the HBIG administration areas:

     Date given mm/dd/yyyy

     Time given –24 hour clock

     Route -IM

     Site RL: right leg; RA: right arm, LL: left leg; RL:  right leg.

     Dose:  in milliliters, decimal provided. 

     MFG: Manufacturer’s codes are printed under this area.

   29b.   Complete the Hepatitis B Vaccine administration areas:

     Date given mm/dd/yyyy

     Time given –24 hour clock

     Route -IM

     Site RL: right leg; RA: right arm, LL: left leg; RL:  right leg.

     Dose:  in milliliters, decimal provided. 

     MFG: Manufacturer’s codes are printed under this area.

30. Darken the circle  “Yes” if mother is HbsAg negative. 

   30a.   Complete the Hepatitis B Vaccine administration areas:

     Date given mm/dd/yyyy

     Time given –24 hour clock

     Route -IM

     Site RL: right leg; RA:  right arm, LL: left leg; RL:  right leg.

     Dose:  in milliliters, decimal provided. 

             MFG: Manufacturer’s codes are printed under this area

31. The RN/LPN administering the immunization(s) will sign and print their licensure title.

32. The RN/LPN administering the immunization(s) will print in the date the immunization(s) given. 

Note:  This form does not remain on the Medical Records.  It is completed and sent to the Arkansas Health Department.  The Incomplete forms will be returned to the unit. The RN/LPN who administered the immunizations will be responsible to correct/complete the forms in a timely manner. 

RESOURCE PERSON(S):   Martha Rabaduex, BSN, RN; Kathy Reedy, RN; Marie Patterson, CSM, BSN, RN

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